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CFR Handout Manual – NYS DOH EMR Compliant – 2012- Revised December 2014 0
Table of Contents
Preparatory: Page:
Introduction to EMS Systems 3
Research / Public Health 6
Communications and Documentation 8
Wellness and Lifts & Carries 11
Medical / Legal 15
Medical Terminology
Medical Terminology 30
Physiology
Pathosphysiology 31
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CFR Handout Manual – NYS DOH EMR Compliant – 2012 - v.3 January 2016
Medicine:
Medical Emergencies 69
Trauma:
Traumatic Emergencies 86
Environmental Emergencies 95
EMS Operations:
Operations 117
START 120
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CFR Handout Manual – NYS DOH EMR Compliant – 2012 - v.3 January 2016
Introduction to EMS System
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CFR Handout Manual – NYS DOH EMR Compliant – 2012- Revised May 2014
Hospital Systems:
Emergency Departments and Specialty Referral Centers
Medical Oversight:
• A formal relationship between the EMS providers and the physician
responsible for the out-of-hospital emergency medical care provided in a
community
• Every EMS System must have medical oversight.
• FDNY EMS operates under the license of the FDNY Medical Director.
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CFR Handout Manual – NYS DOH EMR Compliant – 2012- Revised May 2014
Direct Medical Control (“on-line medical control”) = direction given by the
medical director to a field provider at the time that care is being given.
Communication can be via radio, telephone or actual contact on the scene.
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CFR Handout Manual – NYS DOH EMR Compliant – 2012- Revised May 2014
Research & Public Health
• Findings are important in identifying
EMS Interface
•EMS is a public health system
•Provides a critical function
•Patient care
•Education of the public
•Incorporates services within the EMS system
•Collaborates with other agencies
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CFR Handout Manual – NYS DOH EMR Compliant – 2012- Revised May 2014
•EMS role in health prevention and promotion
–Primary prevention
•Vaccination
•Education
–Secondary prevention
•Preventing complications or the progression of disease
–Health screenings
•Disease and Injury surveillance
–EMS providers are first line care givers
–Patient Care reports offer information on epidemics of disease
–Information collected from reports can help to determine solutions
Safety Equipment
Education
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CFR Handout Manual – NYS DOH EMR Compliant – 2012- Revised May 2014
Communication and Documentation
•Privacy
–Respecting the patient’s right to confidentiality
•Minimizing Interruptions
•Note-Taking
•Physical Environment
–Lighting
–Noise / Outside interference
–Distracting equipment
–Distance
–Equal seating / eye level
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CFR Handout Manual – NYS DOH EMR Compliant – 2012- Revised May 2014
Patient Interview
• Be aware of surroundings
• Introduce yourself and your partner
• Use appropriate titles; Mr. and Mrs.
• Ask what it is you can do for them
• Ask questions one at a time in order to obtain a complete answer
• Utilize an assortment of open or closed ended questions as is pertinent to
the information you are trying to gather
• Open ended questions
• Cannot be answered with a simple yes or no
• Allows the patient to explain what they are feeling
• Closed ended questions
• Simple yes or no answers
• Allows for you to expand on the answer
• Is the pain sharp ?
• Is it a tightness ?
Communication Barriers
• Language
• Visually Impaired
– Speak calmly and with a reassuring voice
– Consider making physical contact with the patient if they extend their
hand to yours
• Hearing Impaired
– Determine the extent of the impairment
– May need to raise your voice or speak slowly so the patient can read
your lips
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CFR Handout Manual – NYS DOH EMR Compliant – 2012- Revised May 2014
System Communications
Documentation
Making a record of the events. It is a basic responsibility of First Responders.
– Functions
– Continuity of care
– Administrative, part of the medical record
– Legal document
• Time of events
• Assessment findings
• Disposition
• Refused care
• Care turned over to another provider
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CFR Handout Manual – NYS DOH EMR Compliant – 2012- Revised May 2014
Wellness
CFRs will commonly experience great personal stress and will encounter
patients and bystanders in severe stress. CFRs must be able to maintain
composure in highly stressful environments and situations.
Stages of Grief:
• Denial
• Anger
• Bargaining
• Depression
• Acceptance
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CFR Handout Manual – NYS DOH EMR Compliant – 2012- Revised May 2014
STRESS MANAGEMENT
Warning Signs of Stress Overload:
• Irritability
• Difficulty concentrating
• Difficulty sleeping
• Anxiety
• Loss of appetite
• Loss of interest in sexual activities, work or activities normally found
enjoyable
• Isolation / Withdrawal from friends & family
Reducing Stress through Healthy Lifestyle Changes
• Diet: reduce sugar, fatty food and alcohol consumption
• Exercise and regular physical activity
• Request change of tour / shift / work location
• Seek professional help when needed
• Practice relaxation techniques
Management includes:
• Pre-incident stress education
• Peer support
• Disaster support services
• Spouse / Family support
• Critical Incident Stress Debriefing (CISD)
- Held within 24 – 72 hours of a major incident
- Open discussion led by CISD team
- All information is confidential
• Defusings
- Less formal and less structured version of CISD
- Allows for initial venting of emotions
- May enhance or eliminate the need for a formal debriefing
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CFR Handout Manual – NYS DOH EMR Compliant – 2012- Revised May 2014
BODY SUBSTANCE ISOLATION
• Gloves must be worn whenever potential for contact with blood or other
body fluids exists and must be changed between contact with different
patients
• When there is a potential for splash or splatter, a gown and surgical type
mask should be worn in addition to gloves.
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CFR Handout Manual – NYS DOH EMR Compliant – 2012- Revised May 2014
Lifting & Moving Patients
Body Mechanics
• Lift with your legs, not your back
• Keep weight as close to your body as possible
• Consider weight of the patient and consider the need for additional help
• Know your physical limitations and the limitations of the equipment
• Communicate
To minimize this risk, make every effort to move the patient in the direction of the long axis of
the body (towards the head or feet).
Patient Positioning
An unresponsive patient without trauma or risk of spinal injury should be moved into the
recovery position
A patient with trauma or a suspected spinal injury should not be moved prior to the arrival
of EMS
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CFR Handout Manual – NYS DOH EMR Compliant – 2012- Revised May 2014
Medical / Legal
The Scope of Practice is enhanced by state and local protocols and by the
direction of medical control.
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CFR Handout Manual – NYS DOH EMR Compliant – 2012- Revised May 2014
CONSENT:
A patient must give consent for any and all medical care.
A CFR must obtain some form of consent prior to initiating ANY treatment.
Consent may be informed (expressed) or may be implied.
Prior to initiating care, a CFR MUST obtain informed consent from ANY
patient who is competent.
The patient must be informed of the CFR’s level of training, the intended
treatment, any risks and benefits associated with treatment and any risks and
benefits of refusing that treatment.
Implied Consent:
A CFR may initiate necessary care of a patient who is not competent to give
actual, informed consent based on the assumption that the patient would
consent to life-saving intervention if he or she were able.
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CFR Handout Manual – NYS DOH EMR Compliant – 2012- Revised May 2014
Refusal of Care:
First Responders DO NOT accept refusals. The CFR must ensure that
additional EMS resources will evaluate the patient.
• They are on an approved NY State DOH form or Medic Alert Tag and
• They are physically present and
• They are valid
Once CPR has been initiated, if a valid DNR is presented Direct Medical
Control (telemetry) must be contacted for approval to discontinue resuscitative
efforts.
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CFR Handout Manual – NYS DOH EMR Compliant – 2012- Revised May 2014
MOLST
• An alternative form for patients to provide their end of life care preference
• Accepted by EMS Agencies, Hospitals, Nursing Homes, and Hospices
• Section A
– For Patients in Cardiopulmonary Arrest
• No Resuscitation
• Full Resuscitation
• Section E
– For Patients NOT in Cardiopulmonary Arrest
• Do Not Intubate
• Mechanical Ventilation Instruction
Abandonment:
Once care has been initiated, a CFR may not leave the scene until patient care
has been transferred to another healthcare provider with equal or higher
training and capabilities. To avoid committing patient abandonment, the CFR
must ensure that patient care will continue at an equal or higher level.
Negligence:
Deviation from the accepted standard of care that results in harm or injury to the
patient
Components of negligence:
• Duty to Act
A contractual or legal obligation exists
• Breach of Duty
Failure to act or failure to act appropriately
• Injury or Damages occurred
May be physical or psychological
• Proximate Cause
The actions or lack of actions directly caused the injury / harm
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CFR Handout Manual – NYS DOH EMR Compliant – 2012- Revised May 2014
Crime Scene Preservation:
• EMS personnel are only allowed to have access to, use or disclose
patient information in connection with their duties as an EMT or
Paramedic.
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CFR Handout Manual – NYS DOH EMR Compliant – 2012- Revised May 2014
• Health Insurance Portability and Accountability Act (HIPAA)
– Refers to privacy and security regulations
– Applies to “protected health information” (PHI) of health care
providers and certain other healthcare entities who are “covered
entities” that engage in electronic transactions
– The Fire Department is a covered entity with respect to its EMS
operations
te
• On-scene disclosure of patient information to law enforcement personnel
should be limited to:
– Date and Time of Treatment
– Name and Address
– Date of Birth
– Social Security #
– Type of injury
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CFR Handout Manual – NYS DOH EMR Compliant – 2012- Revised May 2014
The Human Body
Function:
Anatomy:
• Nose and Mouth
• Pharynx
o Oropharynx
o Nasopharynx
o Laryngopharynx
• Epiglottis = a leaf-shaped structure that prevents food and fluid from
entering the trachea during swallowing
• Trachea = (windpipe) passageway from pharynx (upper airway) to lungs
(lower airway)
• Larynx = voice box
• Lungs = site of gas exchange
• Diaphragm = main muscle of the respiratory system
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CFR Handout Manual – NYS DOH EMR Compliant – 2012- Revised May 2014
Physiology:
Ventilation (breathing) = the mechanical process of moving air in and out of the
airways.
The diaphragm is a muscle located at the base of the chest cavity. When
relaxed, it is dome-shaped, extending up towards the lungs and chest cavity.
When the diaphragm contracts, it flattens out, moving downwards, causing the
lugs to expand. At the same time, muscles located in the chest wall contract
and lift the ribcage up and out, further increasing the size of the chest cavity.
When the size of the chest cavity increases, the gas pressure within that cavity
decreases, causing air to move into the lungs (inspiration/inhalation). The
diaphragm then relaxes and moves upwards while the chest cavity moves
downwards, causing a rise in pressure and air to be exhaled.
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CFR Handout Manual – NYS DOH EMR Compliant – 2012- Revised May 2014
The Circulatory System
Function:
• Delivers oxygen and nutrients to the tissues of the body
• Removes waste products from the tissues
Anatomy:
The chambers which receive blood are called atria (single = atrium), and the
chambers which pump blood away from the heart are called ventricles. The
atria and ventricles are divided by one-way valves which prevent the backflow
of blood.
The right atrium receives blood that has been depleted of oxygen from the
body. This oxygen-poor blood is pumped to the right ventricle, which then
pumps it to the lungs where it picks up more oxygen and deposits the waste
product of respiration, carbon dioxide, to be exhaled.
The newly-oxygenated blood from the lungs returns to the heart and enters the
left atrium. The left atrium pumps the oxygenated blood to the left ventricle,
and the left ventricle then pumps the blood to the body to deliver oxygen to all
of the tissues and cells.
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CFR Handout Manual – NYS DOH EMR Compliant – 2012- Revised May 2014
The Blood Vessels
Arteries = Blood vessels traveling away from the heart
Veins = Blood vessels traveling to the heart
Blood travels from the heart through arteries. The arteries branch off into
smaller vessels, or arterioles, which lead to the tiniest blood vessels, the
capillaries. The capillaries connect arterioles to venules and are the site of
gas exchange.
Because the walls of the capillaries are so thin, gases are able to move across
the walls. When blood that is rich in oxygen moves into a capillary that is
surrounded by oxygen-poor tissue, the oxygen moves from that blood into the
surrounding tissue. At the same time, the carbon dioxide in the surrounding
tissue moves in the reverse direction, from the tissue through the capillary wall
into the blood that had previously had a low level of carbon dioxide.
The blood, which now contains high levels of CO2 and low levels of O2, returns
to the heart via smaller venules and larger veins.
This exchange of oxygen for carbon dioxide is reversed in the lungs, where
blood that is high in CO2 but low in O2 enters the capillaries surrounding the air
sacs (alveoli) of the lungs. The CO2 moves from the blood out into the lungs
and the O2 from the lungs moves into the bloodstream.
Artery Vein
Capillaries
Arterioles Venules
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CFR Handout Manual – NYS DOH EMR Compliant – 2012- Revised May 2014
Blood:
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CFR Handout Manual – NYS DOH EMR Compliant – 2012- Revised May 2014
The Musculoskeletal System
The Skeletal System
Function:
Components:
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CFR Handout Manual – NYS DOH EMR Compliant – 2012- Revised May 2014
The Muscular System
Function:
• Gives shape to the body
• Provides protection for vital organs
• Allows movement
Components:
Voluntary (skeletal) Muscle:
• Attached to bones
• Under conscious control by the nervous system
• Can be contracted and relaxed at will
• Responsible for movement
Cardiac Muscle:
• Found only in the heart
• Can tolerate interruptions of blood supply for only very short times
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CFR Handout Manual – NYS DOH EMR Compliant – 2012- Revised May 2014
The Nervous System
Function:
• Controls both the voluntary and involuntary activity of the body
• Provides for higher mental function (thoughts and emotions)
Components:
Central Nervous System
• Brain
• Spinal cord
All the nerves that branch off from the Central Nervous System and
innervate the body
Motor nerves = nerves which travel from the brain to the body and
carry messages that induce movement
Sensory nerves = nerves traveling from the body back to the brain
and carry messages regarding sensation
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CFR Handout Manual – NYS DOH EMR Compliant – 2012- Revised May 2014
The Skin
The largest organ in the body
Function:
• Protects the body from the environment, bacteria and other organisms
• Helps regulate the temperature of the body
• Prevents dehydration
• Senses heat, cold, touch, pressure and pain
Changes in skin color, temperatures and condition (wet or dry) are important
diagnostic signs and can be extremely informative concerning patient’s
condition.
Skin will normally feel warm to the touch. Temperature should be assessed on
the core of the body (face, neck, torso).
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CFR Handout Manual – NYS DOH EMR Compliant – 2012- Revised May 2014
Medical Terminology
Common Terms
Medical Prefixes
•Cardio- (Heart)
•Neuro- (Nerves)
•Hyper- (Above Normal)
•Hypo- (Below Normal)
•Naso- (Nose)
•Oro- (Mouth)
•Arterio- (Arteries)
•Hemo- (Blood)
•Therm- (Heat)
•Vaso- (Blood Vessel)
•Tachy- (Rapid)
•Brady (Slow)
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CFR Handout Manual – NYS DOH EMR Compliant – 2012- Revised May 2014
Pathophysiology
• INHALED AIR
21 % Oxygen
78 % Nitrogen
• EXHALED AIR
16 % Oxygen
78 % Nitrogen
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CFR Handout Manual – NYS DOH EMR Compliant – 2012- Revised May 2014
• ABC’s MUST be managed properly to ensure brain viability.
• Nasopharynx
• Oropharynx
• Pharynx
• Larynx
• Trachea
• Bronchi
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CFR Handout Manual – NYS DOH EMR Compliant – 2012- Revised May 2014
Airway compromise
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CFR Handout Manual – NYS DOH EMR Compliant – 2012- Revised May 2014
Shock
• Referred to as hypo-perfusion
Causes of Shock
• Heart
• Blood vessels
– Inability to constrict
– Related to spinal cord injury, infection, or anaphylaxis
• Blood
– Decrease in the amount of blood or blood components in the
blood vessels
– Related to bleeding, vomiting, diarrhea, or burns
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CFR Handout Manual – NYS DOH EMR Compliant – 2012- Revised May 2014
Life Span Development
Infants:
• Newborn
Few hours old
• Neonates
Until 1 month old
• Infant
1-12 months old
• Heart Rate
140-160 bpm during first 30mins
• Respiratory Rate
Initially 40-60 breaths/min
Drop to 30-40 breaths/min few min after birth
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CFR Handout Manual – NYS DOH EMR Compliant – 2012- Revised May 2014
• Blood pressure
– Average of 70 mm Hg systolic at birth
– Increases to 90 mm systolic Hg by age 1
• Temperature
– 98 to 100 degrees Fahrenheit
• Weight
– Normally 3-3.5 kg (6-8 lb) at birth
– Initially drops 5-10% in the first week of life
• Gain of 30 g/day 1st month
• Doubling by 4-6 months
• Tripling at 9-12 months
• Airways
– Shorter and Narrower
– More easily obstructed
– Tongues are very large in relation to the mouth
• Can become an obstruction
– Primarily nose breathers until 4 weeks old
– Rapid respiratory rates lead to heat and fluid loss
• Preschooler
3-5 years old
• Heart Rate
80-130 beats/min for toddlers
80-120 beats/min for preschoolers
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CFR Handout Manual – NYS DOH EMR Compliant – 2012- Revised May 2014
• Respiratory rate
20-30 breaths/min for both groups
• Blood pressure
– Systolic blood pressure determination
• 70 + (2 x age in years)
• 70-100 mm Hg for toddlers
• 80-110 mm Hg for preschoolers
Adolescence
• 13-18 years
• HR: 55-105 beats/min
• RR: 12-20 breaths/min
• Systolic BP:80-120 mm Hg
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CFR Handout Manual – NYS DOH EMR Compliant – 2012- Revised May 2014
Early Adulthood
• Age 20 to 40
• Heart Rate: 70 beats/min
• Respiratory Rate: 16-20 breaths/min
• Blood Pressure
• average BP: 120/80 mm Hg
• Temperature
• Core temp: 98.6°F
Middle Adulthood
• Age 41-60
• Heart Rate: 70 beats/min
• Respiratory Rate: 16-20 breaths/min
• Blood Pressure
• average BP: 120/80 mm Hg
• Temperature
• Core temp: 98.6°F
Late Adulthood
• Over 61 years old
• Heart Rate, Respiratory Rate, Blood Pressure
• All depends on the patient’s physical and health status
• Temperature
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CFR Handout Manual – NYS DOH EMR Compliant – 2012- Revised May 2014
AIRWAY & OXYGEN
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CFR Handout Manual – NYS DOH EMR Compliant – 2012- Revised May 2014
AIRWAY MAINTENANCE
Opening the airway of an unresponsive patient is one of the most important
actions that the CFR can perform. When a patient’s mental status decreases,
so does his or her ability to control his or her airway. An unresponsive patient
loses muscle tone and if he or she is not properly positioned the tongue is likely
to fall back in the throat and occlude the airway.
Since the tongue is attached to the lower jaw, moving the jaw forward will lift the
tongue from the back of the throat and prevent airway occlusion. This is
achieved by performing either the head-tilt chin-lift or jaw thrust without
head-tilt.
Head-Tilt Chin-Lift:
The head-tilt chin-lift is the preferred method for opening the airway in an
uninjured patient.
Technique: place your hand that is closer to the patient’s head on his/her
forehead and apply firm backward pressure to tilt the head back. Place the
fingers of your hand that is closer to the patient’s feet on the bony part of his/her
chin. Lift the chin forward and support the jaw.
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CFR Handout Manual – NYS DOH EMR Compliant – 2012- Revised May 2014
Jaw-Thrust without Head-Tilt:
The jaw thrust is the safest method for opening the airway of a patient
with a possible spinal injury.
Technique: Grasp the angles of the patient’s lower jaw and lift with both hands,
displacing the mandible forward. If the lips close, open the lower lip with your
thumb
Airway Adjuncts:
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CFR Handout Manual – NYS DOH EMR Compliant – 2012- Revised May 2014
Sizing:
Measure from the corner of the patient’s lips to the earlobe, or center of
the lips to the angle of the jaw
Insert upside-down, with the tip facing the roof of the patient’s mouth.
Advance gently until resistance is met. Then begin to turn the airway 180
degrees while continuing to insert it, so that it comes to rest with the
flange on the patient’s teeth.
Sizing:
Measure the length from the tip of the nose to the tip of the patient’s ear.
The diameter should not be so large as to cause blanching of the nostril.
The NPA is inserted posteriorly, with the bevel towards the septum.
The right nostril is preferred. If resistance is met the airway should be removed
and inserted in the left instead. Do not force the airway.
The NPA must not be used on a patient with suspected head or facial
trauma!
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CFR Handout Manual – NYS DOH EMR Compliant – 2012- Revised May 2014
Suction:
Mechanical suction devices are used for the removal of blood, vomitus
and other liquids from the airway. Suction units are inadequate for
removing solid particles from the airway. These should be removed by
the use of finger sweeps.
The mechanical suction device in use by the FDNY is functioning properly when
it is capable of generating a minimum of 300 mmHg vacuum power.
A rigid suction catheter should be used and the tip of the catheter should not be
inserted deeper than the base of the patient’s tongue.
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CFR Handout Manual – NYS DOH EMR Compliant – 2012- Revised May 2014
Oxygen Delivery Devices:
Full oxygen cylinder = approximately 2,000 psi
Replace at 200 psi
Non-Rebreather Mask:
• Preferred device for administering supplemental oxygen to patients
in the pre-hospital setting
• Can deliver up to 90% oxygen
• Non-rebreather bag must be filled prior to placing the mask on the
patient’s face
• Liter flow rate should be adjusted so that when the patient inhales the bag
does not collapse (15 LPM)
Nasal Cannula:
• Used only on patients who will not tolerate a non-rebreather mask
despite encouragement from the First Responder
• Rarely the best method of oxygen delivery
• Does not deliver high concentration oxygen: low flow rate device with a
maximum liter flow of 6 LPM
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CFR Handout Manual – NYS DOH EMR Compliant – 2012- Revised May 2014
Bag-Valve-Mask:
• The bag-valve-mask device is most effective and is the preferred
device when two rescuers are available to ventilate. One rescuer
can maintain an airtight seal using both hands and the other rescuer
should squeeze the bag
• Maintaining an adequate seal is difficult with a single rescuer
• Cannot be used by a single rescuer while performing a jaw-thrust
• When using a bag-valve-mask it is always preferred that supplemental
oxygen be attached
Mouth-to-Mask:
• Preferred, most effective device for the single rescuer as it allows for a
two-handed seal
• Can be used with or without supplemental oxygen
While still permitted for use when ventilating an adult patient as per NY State
protocols, NY City protocols prohibit the use of manually triggered positive
pressure devices due to the danger of over-inflating the patient’s lungs.
Mask–to–Stoma Ventilations:
A stoma is a surgical opening in the front of the neck that leads directly to the
trachea. Rescue breathing of this patient requires mask-to-stoma ventilations.
• Use the infant or child mask to create an airtight seal around the stoma.
• The patient’s head and neck do not need to be positioned for airway
maintenance
• If air escapes through the nose and mouth while attempting to ventilate
the stoma, close the mouth and pinch the nostrils. Otherwise it is not
necessary to do so.
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CFR Handout Manual – NYS DOH EMR Compliant – 2012- Revised May 2014
Intranasal Naloxone
Administration for CFR’s
Nasal Naloxone
• Patient (Symptoms)
• Medication (Naloxone)
• Expiration (Non Expired)
• Route (Intra Nasal Delivery)
• Dose (1 to 2 mg based on patient age)
• Time (Administered)
Relative Contraindications
• Cardiac Arrest
• Seizure Activity
• Nasal Trauma
• Epistaxis or other Nasal Obstruction
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Opioids
48
Indications of an Overdose
49
Administering Nasal
Naloxone
51
• Be aware of possible reactions:
– Withdrawal type symptoms
– Agitation, combative
– Nausea and vomiting
– Seizures
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Shock and Resuscitation
Cardiac Arrest = the heart has stopped, no pulse can be felt
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CFR Handout Manual – NYS DOH EMR Compliant – 2012- Revised May 2014
Automated External Defibrillation (AED)
• Used to correct electrical abnormalities in the heart
• Cannot detect mechanical function (a pulse)
• Is to be used in conjunction with CPR
o Perform CPR after each shock is administered
o Perform CPR anytime a shock is not indicated after
analysis
AED Safety
• DO NOT use the AED in a moving vehicle or unstable
environment
• DO NOT touch the patient while the AED is analyzing or
delivering a shock
• Prior to applying the electrodes ensure that the patient’s
chest is dry
Remove any medication patches and wipe any medication paste from
the patient’s skin
Special Considerations
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CFR Handout Manual – NYS DOH EMR Compliant – 2012- Revised May 2014
Left Ventricular Assist Device
• Mechanical circulatory device
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CFR Handout Manual – NYS DOH EMR Compliant – 2012- Revised May 2014
AHA ADULT CHILD INFANT
Puberty and Older 1 year – about 12-14 yrs (<1 year)
2015 Standards
FBAO
Conscious Victim Abdominal Thrusts Abdominal Thrusts Back Slaps/Chest Thrusts
( Heimlich Maneuver ) ( Heimlich Maneuver ) (no abdominal thrusts)
FBAO For Known Choking Patients (Responsive then Unresponsive) : Begin CPR, Looking for
Unconscious Victim Objects Prior To Ventilating.
For Patients Who Are Initially Found Unresponsive,: Initiate the CAB Sequence
Pulse Check
Carotid
Carotid Brachial
No More than 10
No More than 10 Seconds No More than 10 Seconds
Seconds
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CFR Handout Manual – NYS DOH EMR Compliant – 2012- Revised May 2014
THINGS TO REMEMBER
RESCUE BREATHING:
• ADULT-1 BREATH EVERY 5-6 SECONDS
• CHILD-1 BREATH EVERY 3-5 SECONDS
• ADULT, CHILD OR INFANT- ADVANCED AIRWAY IN PLACE (INTUBATED), 1
BREATH EVERY 6-8 SECONDS
DEPTH OF COMPRESSIONS:
• ADULT-2 INCHES to 2.4 INCHES (5-6 CM)
• CHILD- 1/3 DEPTH OF CHEST OR 2 INCHES
• INFANT- 1/3 DEPTH OF CHEST OR 1 1/2 INCHES
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CFR Handout Manual – NYS DOH EMR Compliant – 2012- Revised May 2014
SHOCK (Hypoperfusion)
The condition resulting from the inadequate delivery of oxygenated blood to
body tissues
The function of the circulatory system is to deliver oxygen and nutrients to all of
the tissues of the body, and remove wastes. If the oxygen demands of the
body are being sufficiently met, the body is in a state of perfusion.
Management:
Administer oxygen
DO NOT allow patient to eat or drink anything
Maintain normal body temperature / prevent heat loss
Elevate lower extremities if possible without aggravating injuries
Prevent further blood loss
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CFR Handout Manual – NYS DOH EMR Compliant – 2012- Revised May 2014
PATIENT ASSESSMENT
Scene Size-Up:
Begins with dispatch information. En route to and upon arrival on the scene,
consider issues affecting:
Scene Safety: En route to the scene, consider the possibility of any hazards
that may exist. While approaching and upon arrival at the scene, assess the
surroundings for any potential hazards to safety of self, crew, patient and
bystanders.
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CFR Handout Manual – NYS DOH EMR Compliant – 2012- Revised May 2014
Primary Assessment:
Performed to identify and immediately correct life-threatening illness or
injuries
General Impression:
The CFR’s immediate assessment of the environment and the patient’s chief
complaint or appearance / positioning / apparent severity of condition
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CFR Handout Manual – NYS DOH EMR Compliant – 2012- Revised May 2014
Mental Status:
Assess the patient’s mental status. Begin by speaking to the patient.
Determine level of responsiveness using AVPU scale:
A = alert
V = responds to verbal stimulus
P = responds to painful stimulus only
U = unresponsive
AIRWAY:
Responsive patient – Is the patient talking or crying?
Unresponsive patient – Is the airway open and will it stay open?
Open the airway with a jaw thrust or head-tilt chin-lift as necessary
Inspect for any obstructions, unusual noises, etc. Clear and suction as
needed
Once opened and cleared, maintain with adjunct (OPA or NPA) as needed
BREATHING:
Is the patient breathing adequately to sustain life?
If yes: administer oxygen via non-rebreather at 15 LPM
If No: ventilate with supplemental oxygen
Assess the chest for and treat signs / symptoms of chest injuries that will impair
breathing.
Seal any open wounds to the chest with an occlusive dressing taped on 3
sides.
Impaled objects should be stabilized in place.
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CIRCULATION:
Assess for the presence and quality of pulse
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Secondary Assessment:
Briefly inspect (look) and palpate (feel) for any signs of injury, or:
D – Deformities
O – Open injuries
T – Tenderness
S – Swelling
Head
↓
Neck
↓
Chest
↓
Abdomen
↓
Pelvis
↓
Lower extremities (legs)
↓
Upper extremities (arms)
Secondary Injuries discovered during the physical exam can be treated as time
permits.
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VITAL SIGNS
Pulse:
A pulse can be palpated anywhere on the body where an artery passes over a
hard structure or bone. The pulse should be assessed for both rate and
quality.
Respirations:
Breathing is assessed by watching the rise and fall of the patient’s chest.
Respirations should be assessed for both rate and quality.
Care should be taken to not inform the patient that this is being done as that will
influence their breathing.
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Blood Pressure:
Skin:
The patient’s skin color should be assessed in the nail beds, oral mucosa (lips,
gums) and conjunctiva (inside eyelids).
Normal = pink
Abnormal = pale, cyanotic, flushed or jaundiced
The patient’s skin temperature should be assessed by placing a gloved hand
on the patient’s skin, preferably centrally located (face, neck, torso).
Normal = warm
Abnormal = cool, cold, hot
The patient’s skin condition should be assessed by observing for moisture and
sweating.
Normal = dry
Abnormal = wet, moist, clammy
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History & Physical Exam:
MEDICAL HISTORY:
Obtain pertinent medical history from patient, family or friends if possible
Sign = something which can be verified (seen, heard, felt, smelled, etc) by the
rescuer (ex. - fever, cyanosis, noisy breathing)
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Reassessment:
Upon arrival of the EMS unit, the CFR should provide a hand-off report
consisting of:
• Age and sex
• Chief complaint
• Mental status/responsiveness
• Airway, breathing & circulatory status
• Physical findings
• SAMPLE history
• Interventions provided
If at any time during the assessment the patient’s mental status changes,
begin the primary assessment over, starting with the “AVPU” step
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Pt. Assessment Flow Sheet
Scene Size-up: Ask 5 questions
Is the scene safe?
Do I have enough BSI?
What is the MOI/NOI?
How many patients are there?
Do I need additional resources?
Primary Assessment
L – Are there any obvious, immediate Life threats?
I – “I see…” (general impression)
S – Consider the need for Spinal Stabilization
A – AVPU
A – Airway (OSO)
Open the airway (jaw thrust or head-tilt chin lift)
Suction and clear the airway if needed
OPA/NPA
B – Breathing (O-IPASS)
Oxygen: “Is the patient breathing adequately?”
If yes, oxygen via NRB. If no, oxygen via BVM
Inspect (look)
Palpate (feel)
Auscultate (listen for the lungs sounds, mid-axillary)
Seal any open wounds with an occlusive dressing
Stabilize any impaled objects with a bulky dressing
C – Circulation (VCRSS)
Voids – assess for major bleeding and treat if found
Carotid pulse – assess presence and quality
Radial pulse - assess presence and quality
Skin - assess color, temperature and condition
Shock – treat as necessary
Reassessment
Repeat Vital Signs
Repeat Primary Assessment
Repeat Secondary Exam
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Medicine
Respiratory Distress
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Management:
Complete primary assessment
Chest Pain
A complaint of chest pain must always be considered to be potentially
life-threatening
Muscle strain
Respiratory – related (pneumonia, respiratory infection)
Trauma
Angina
Heart Attack
Management:
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Altered Mental Status (AMS)
A sudden or gradual decrease in the patient’s level of responsiveness and
understanding, ranging from disorientation to complete unresponsiveness which
may be a brief period or prolonged.
Management:
• CFR’s role is to support the patient, regardless of the cause of AMS
• Maintain scene safety, retreat if necessary
• Complete the Patient Assessment and administer oxygen
• Monitor airway carefully, have suction available
• Place patient in recovery position unless possibility of spinal injury exists
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Seizures
A sudden attack, usually related to a malfunction of the nervous system.
Common causes:
• Chronic medical conditions • Low blood sugar
(epilepsy) • Head trauma
• Fever • Hypoxia
• Infections • Brain tumors
• Poisonings • Complication of pregnancy
• Alcohol / Drugs
Management:
Of an actively seizing patient:
• DO NOT ATTEMPT TO RESTRAIN THE PATIENT
• DO NOT PUT ANYTHING IN THE PATIENT’S MOUTH
• Attempt ventilations; may be impossible
• Protect the patient from harm as best as possible
• Observe and record seizure activity
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Stroke (Cerebro-Vascular Accident)
A sudden interruption of blood flow to a portion of the brain resulting in
tissue death
Dependent upon what portion and how much brain matter is affected, and
may include:
• Severe headache
• Lack of speech
• Difficulty swallowing
• Facial droop
• Unequal pupils
• Paralysis/numbness
• Loss of bowel or bladder control
• AMS/unresponsiveness
Management:
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Abdominal and Gastrointestinal
Abdomen:
Treatment
Special Considerations
•Evisceration:
–Do NOT replace the protruding organ
–Position the patient with the knees slightly bent
–Place sterile, saline moistened dressings over the organ.
Do not pour fluids over the wound
–Secure dry, bulky dressings over the moist
–Place an occlusive dressing as the final layer
•Impaled Object:
–Do NOT remove the object
–Support and secure with bulky dressings
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Gastrointestinal Distress
Treatment
•Genitourinary System
–Incorporates all of the organs responsible for reproduction
and urinary excretion
•Renal System
–Organs responsible for the elimination of urine
–Kidneys, ureters, bladder, and the urethra
Hemodialysis
Treatment
•Maintain an airway
•Administer oxygen
•Ventilate if indicated
•Control bleeding from the shunt
•Position:
–Flat if showing signs of shock
–Upright if having difficulty breathing
Gynecological Emergencies
•Polyps or lesions
•Cancer
•Cysts
•Fibroids
•Infection
•Trauma
Treatment
•Administer oxygen
•Treat as any soft tissue injury
•Apply external pads; never pack the vagina
•Treat for shock if indicated
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Immunology
•Allergic reaction
•Anaphylaxis
Common Allergens
•Insect venom
•Food
•Medication
•Animal dander
•Pollen
Assessment
•Respiratory system
–Severe respiratory distress
–Wheezing
–Constriction of the airway
•Cardiovascular system
–Rapid pulse
–Low blood pressure
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•Skin
•Pale, red, or cyanotic
•Hives
•Itching
•Swelling around the eyes, mouth, and tongue
Management
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Behavioral Emergencies
Behavior = manner in which a person acts or performs; any and all activities of a
person, including physical and mental activity.
Behavioral emergency = a situation where the patient exhibits abnormal behavior that
is unacceptable or intolerable to the patient, family or community.
Restraining patients:
Restraint should be avoided unless patient is a danger to self or others. Have police
present if possible and get approval from medical control.
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Toxicology
Poison
–Any substance which can be harmful to the body
Carbon Monoxide
•Symptoms include:
–Headache
–Dizziness
–Nausea
–vomiting
•Management:
•Remove the patient(s) from the environment
•Perform a complete assessment
•Administer high concentration oxygen
•Patient may need to go to the hyperbaric chamber
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NERVE AGENTS
• Attack respiratory and nervous systems within seconds to minutes
• Extremely toxic lethal agents
• Similar to pesticides in function
• Tabun (GA)
• Sarin (GB)
• Soman (GD)
• V agent (VX)
Management
• Scene safety including specialty units
• Appropriate BSI and PPE
• Remove patient from contaminated environment
• Decontamination from trained personnel
• Airway maintenance
• Oxygenate and ventilate
• Administer nerve agent auto injector kit to self or other rescuer if
indicated and available
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Medical Treatment for Chemical Nerve Agents
Mark I Antidote Kit - (2) Auto-Injectors
600 mg. Pralidoxime
2 mg. Atropine
DuoDote Antidote Kit
- Single auto Injector
- Dual Chambered
- Contains:
2.1 mg of Atropine and 600 mg of 2-PAM
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REMAC Exposure Protocol Initial Treatment
Severe Respiratory
6 mg
Distress, 3 Auto – Injector
RED Monitor every 5
Agitation, Kits
min
SLUDGEM
ORANGE 4 mg
Respiratory Distress, 2 Auto - Injector
or Monitor every 10
SLUDGEM Kit
YELLOW min
None
GREEN Asymptomatic None Monitor every 15
min
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REMAC Exposure Protocol
Re-Evaluation and Treatment
Atropine
Signs & Monitor Auto Injector Repeat
Tag Color
Symptoms Interval Admin. Dosing
Freq.
Severe 2 mg every
Up to
Respiratory 3-5
maximum
RED Distress, 5 minutes minutes
of 3 auto
Agitation, as
injectors
SLUDGEM needed
2 mg every
Up to
ORANGE Respiratory 5-10
maximum
or Distress, 10 minutes minutes
of 2 auto
YELLOW SLUDGEM as
injectors
needed
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REMAC Exposure Protocol
Pediatric Patients
Exposure and /
or signs of
Atropine Dose &
SLUDGEM, Atropine and Antidote Kit
Tag Color Monitor
Agitation, and Doses & Monitor Interval Interval
Respiratory
Distress
1 PEDS
Atropine
Auto-
Injector,
Less than 1 No
years old Antidote
Kit, Atropine
Monitor every 3
RED Yes every 3 minutes
minutes as
needed
1 Antidote
Kit,
1 - 8 years old Monitor
every 3
minutes
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Trauma
BLEEDING
Bleeding can be internal or external. Uncontrolled bleeding, either internal
or external can lead to significant blood loss, shock and death.
The normal response of the body to blood loss is blood vessel contractions
and clotting.
The average 150 lb. adult male has approximately 6 Liters of blood.
A smaller person has less, and will therefore suffer the effects of blood loss
after a smaller loss of volume.
EXTERNAL BLEEDING
Characteristics of Bleeding:
Arterial bleeding:
• Bright red (due to higher oxygen content)
• Spurts from the wound
• Most difficult type of bleeding to control
• Spurting may cease as blood pressure drops
Venous bleeding:
• Dark red (oxygen poor)
• Flows in a steady stream
• Can be profuse but easier to control
Capillary bleeding:
• Dark red in color
• Oozes from the wound
• Often clots spontaneously
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Control of External Bleeding:
Dressing = applied directly to the wound, prevents contamination
Bandage = holds the dressing in place, can provide pressure
• Direct pressure
STATE:
Turn until bleeding stops
CITY:
Turn until bleeding stops and distal
pulses aare absent
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INTERNAL BLEEDING
Injured or damaged internal organs often lead to concealed
bleeding. Painful, swollen deformed extremities also often lead
to serious internal bleeding.
Management:
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SOFT TISSUE INJURIES
Abrasion:
• scrape / “road rash”
• tearing away of outermost layer of skin
• very little or no oozing of blood
Laceration:
• break in skin of varying depth
• bleeding may be severe
• caused by sharp object
Penetration / Puncture:
• caused by sharp pointed object
• may be little or no external damage
• internal damage may be severe
• may be entrance or exit wound
Management:
• complete patient assessment
• administer oxygen
• expose the wound
• control the bleeding
• prevent further contamination
• apply sterile dressing and bandage in place
SPECIAL CONSIDERATIONS
Nose Bleeds (Epistaxis)
Pinch the nostrils closed and have the patient lean forwards to prevent the
flow of blood from entering the airway.
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Chest Injuries
ANY open wound to the chest or upper back should be sealed with an
occlusive dressing taped on three sides. A corner should be left unsealed
to create a flutter-valve. If at any time the patient’s condition deteriorates,
ensure that the flutter valve is functioning properly.
Impaled Objects
Removal of an impaled object may lead to uncontrolled profuse bleeding.
Eviscerations
An evisceration is an open injury through which organs are protruding.
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Amputations
Complete or near-complete tearing off of a body part, most commonly
extremities but may also involve an ear or the nose
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Injuries to Muscles and Bones
Types of Musculoskeletal Injuries:
Sprains
Strains
Fractures
o Open
o Closed
Dislocations
Mechanisms of Injuries:
Direct force – injury occurs at the site of impact
Indirect force – injury occurs away from the impact
Torsion – twisting
Management
Injuries to muscles and bones are managed after all life-threats have been
addressed
Complete the patient assessment
Manually stabilize the injury site and adjacent joints
Cover any open wounds with a dry, sterile dressing
Apply a cold pack
DO NOT attempt to replace protruding bone ends
DO NOT attempt to straighten deformed joints – stabilize in the
position found
Providing resistance is not encountered, angulated bones may be
straightened into a splintable position – otherwise stabilize in the
position found
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Injuries to the Spine and Spinal Cord
Spinal injuries may cause permanent disability or death
Management
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Head Injuries
Can be open or closed
Bleeding within the skull or injuries to brain tissue resulting in swelling may
cause an increase in pressure on the brain.
Management
Complete the patient assessment
Monitor and maintain airway
Administer oxygen, ventilate as needed and monitor for respiratory
arrest
Control bleeding
o Apply enough pressure to scalp injuries to control bleeding
without disturbing the underlying tissue
o DO NOT apply firm direct pressure to scalp / head injuries
Monitor mental status
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Environmental Emergencies
Exposure to Cold
Management:
• Remove the patient from the cold environment, and remove any wet
clothing
• Cover with a blanket, protect from further heat loss
• Handle the patient extremely gently – do not allow the patient to
walk or exert himself / herself
• Do not allow the patient to eat or drink anything or to smoke
• Do not massage the extremities
• Complete a Patient Assessment, administer oxygen
• Assess pulse for 30 – 45 seconds prior to initiating CPR
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Local Cold Emergencies (Frostbite)
Freezing or near-freezing of a body part, usually occurring in fingers, toes,
face, ears and nose.
Management:
• Remove the patient from the cold environment
• Protect the injured extremity from further injury
• Remove wet or restrictive clothing
• Manually stabilize the extremity
• Remove jewelry
• Cover with dry dressing
• DO NOT:
• Break blisters
• Rub or massage area
• Apply heat or attempt to re-warm
• Allow the patient to walk on the affected extremity
• Re-expose to the cold
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Exposure to Heat
Contributing Factors:
• High temperatures - reduces the body’s ability to lose heat by
radiation
• High humidity reduces ability to lose heat by evaporation
• Exercise and activity
• Age (very old / very young)
• Pre-existing medical conditions
• Drug / Alcohol use
Management:
• Remove the patient from the hot environment
• Cool patient by fanning
• Place in recovery position
A patient with hot, flushed skin that is dry (no longer sweating) is
suffering from HEAT STROKE.
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BURNS
Classification is done according to depth:
Superficial:
• Outer layer of skin only
• Redness and swelling
Partial Thickness:
• Outer and middle layer of skin
• Deep, intense pain
• Reddening and blistering
Full thickness:
• Extends through all the layers of the skin
• Areas of black, charred skin
• All characteristics of partial thickness will also be present
Management:
• FIRST STOP THE BURNING PROCESS WITH WATER OR
SALINE!
• Remove any smoldering clothing or jewelry provided resistance is not
met
• Continually monitor the airway for evidence of closure / swelling
• Administer oxygen
• Prevent further contamination
• Cover the burned area with dry, sterile dressing, then wrap in dry,
sterile sheets
• Do not use any type of ointment, lotion or antiseptic
• Do not break any blisters
Thermal Burns:
Cool hot or smoldering skin (up to 20% of body surface area at a time) with
cool water, Normal Saline (0.9%NS), or saline – moistened, sterile
dressings
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Chemical Burns:
• Scene safety!
• Brush off any dry powder, blot off any liquid prior to flushing
• Flush with copious amounts of water for a minimum of 20 minutes
• Consider possibility of splash injuries to eyes – flush with copious
water from bridge of nose outwards FLUSH SKIN / EYES
• Be sure to avoid run-off
NY STATE: 20 MINS / 20 MINS
Electrical Burns: NY CITY: 10 MINS / 20 MINS
Rule of
Nines
Chest = 9 %
Abdomen = 9 %
Chest 9 %
Abdomen
9%
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Obstetrics
ANATOMY & TERMINOLOGY
Fetus = developing unborn baby
Uterus = organ in which a fetus grows, responsible for labor and expulsion
of the infant
Birth Canal = The lower part of the uterus (cervix and the vagina)
Amniotic Sac = the sac that surrounds the fetus inside the uterus,
provides shock absorption and regulates temperature
Crowning = the bulging out of the vagina as the presenting part of the
fetus begins to press against it
“Bloody Show” = mucous and blood that may be expelled from the vagina
as labor begins
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CFR Handout Manual – NYS DOH EMR Compliant – 2012- Revised May 2014
Pre-Delivery Emergencies
Miscarriage
• Provide comfort & psychological support in addition to physical care
• Retain any expelled materials
• Assess for and treat shock as necessary
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Assisting With the Delivery
As the head emerges, apply gentle pressure with your hand to prevent an
explosive delivery. Use other hand to support the perineum to prevent it
from tearing.
If the amniotic sac has not broken, immediately tear it and clear it away
from the baby’s nose and mouth.
Immediately following delivery of the head, check for the presence of
the umbilical cord around the baby’s neck. If the cord is looped around
the neck, attempt to slip it over the baby’s head.
NY City – if you are unable to slip the cord over the baby’s head,
immediately clamp and cut the cord between the clamps
NY City:
After delivery of the head, suction first the mouth and then the
nose using a bulb syringe, or clear the mouth and nose with gauze
NY State:
DO NOT suction unless there is an obstruction or ventilations are
required.
Support the baby as the torso is delivered. Do not pull on the baby; grasp
the feet as they are delivered.
Keep the newborn at about the level of mom’s vagina until cord is clamped
NY City: after pulsating stops, clamp and cut the umbilical cord: fasten 1st
clamp 8 – 10 inches away from newborn, 2nd clamp approximately 4 inches
from newborn. Cut between the clamps
Warm, dry and stimulate the newborn, keeping the newborn’s head slightly
lower than the torso. Record time of delivery and monitor the newborn’s
condition closely.
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CFR Handout Manual – NYS DOH EMR Compliant – 2012- Revised May 2014
Assessment and Care of the Newborn
Spontaneous respirations should begin within 30 seconds of birth
→Stimulate by warming, drying, and lightly flicking the soles of the feet or
rubbing the back
If the newborn’s heart rate drops below 100 beats per minute
at any time, begin assisted ventilations.
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CFR Handout Manual – NYS DOH EMR Compliant – 2012- Revised May 2014
Newborn Resuscitation
Perform CPR with a compression to ventilation ratio of 3:1 with a
compression rate of 120 compressions / minute.
Once the heart rate is greater than 100, stop CPR and continue assisted
ventilations at a rate of 40 – 60 breaths / minute.
Continue ventilations until the heart rate is greater than 120 beats / minute,
respirations are greater than 30 breaths / minute and central cyanosis
disappears. Continue oxygen administration via blow-by.
Special Considerations
Prolapsed Cord
• Condition where the cord presents before delivery of the head,
compression of the cord will cut off blood and oxygen supply to baby.
• Immediately notify incoming EMS unit; elevate mother’s hips /
buttocks; advise her not to push
Multiple Births
• will need to prepare for the delivery of a second infant in addition to
caring for the first and the mother
• usually smaller, often premature and at risk for complications
• delivery of subsequent newborn(s) is handled in the same manner as
the first
Premature Births
• always at greater risk for hypothermia
• usually require resuscitation
• attempt resuscitation unless physically impossible
Presence of Meconium
• discolored greenish-brownish amniotic fluid
• may indicate fetal distress
• newborn requires thorough suctioning of oropharynx prior to
stimulating
• advise EMS and document
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CFR Handout Manual – NYS DOH EMR Compliant – 2012- Revised May 2014
Abnormal Presentations
Breech
• poses greater risk of delivery trauma to mother and newborn
• Immediately notify incoming EMS unit upon recognition.
• If breech does not deliver, elevate mother’s hips / buttocks and
advise her not to push.
• Apply high concentration O2
Limb Presentation
• a limb (most commonly a foot) is the presenting part
• Cannot deliver in pre-hospital setting
• Immediately notify incoming EMS unit, elevate mother’s hips /
buttocks and advise her not to push.
• Apply high concentration O2
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CFR Handout Manual – NYS DOH EMR Compliant – 2012- Revised May 2014
Pediatrics
Anatomical Differences
Airway
• All structures are smaller and more easily obstructed
• Narrower trachea
• Easily blocked by secretions or swelling
• Tongue is large relative to lower jaw and can block airway
easily in an unresponsive child / infant
• Soft trachea → hyperextension of neck will block airway
rather than open it
• Infants rely heavily on nose-breathing; adequate suctioning
of nasopharynx is critical
• OPA should only be used when ventilations are
unsuccessful without one
• OPA is inserted anatomically to depress the tongue down
and out of the way
• NPAs are not used in children by CFRs
Physiological
• Compensate for respiratory problems or shock VERY well
Increased respiratory rate
Increased breathing effort
• Compensation is followed rapidly by decompensation due to
fatigue from work at compensating
• Greater risk of hypothermia – lose heat more quickly
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Assessment of the Pediatric Patient
• Breathing effort
• Chest movement / expansion / symmetry
• Retractions
• Nasal flaring
• Stridor or other noisy breathing
• Respiratory rate
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Appearance
Work of
Breathing
Pediatric
Assessment
Triangle
Circulation to the Skin
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Common Problems in Pediatrics
Airway Compromise:
Management
• Allow position of comfort
• Offer oxygen via NRB or blow-by
• DO NOT AGITATE
Management
Manage airway in accordance with current AHA guidelines
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CFR Handout Manual – NYS DOH EMR Compliant – 2012- Revised May 2014
Respiratory Distress
Management:
Offer supplemental oxygen via NRB
Respiratory Failure
Management:
Assist ventilations with a bag-valve mask device with supplemental oxygen
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Circulatory Failure
Signs & Symptoms
• Increased heart rate
• Central pulses stronger than peripheral pulses
• Signs of poor perfusion (pale, cool, mottled)
• Altered mental status
Management:
Uncorrected circulatory failure is also a common cause of cardiac arrest in
infants and children. Support oxygenation and ventilation and monitor
closely for cardiac arrest
Seizures
Common causes:
• Fever = most common cause of seizures in children
• Trauma
• Infections
• Poisonings
• Low blood sugar
• Hypoxia
Management:
Seizures should be considered potentially life-threatening in pediatrics
Following seizure:
• assure patency of airway
• assist ventilations as needed
• place in recovery position if no concern of spinal injury
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Altered Mental Status
Common causes:
• low blood sugar
• high blood sugar
• poisoning
• post seizure
• infection
• head trauma
• hypoxia
Trauma
Blunt injury is the most common, often from motor vehicle collisions, falls,
burns, sports injuries or child abuse / neglect
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Geriatrics
•Experience changes in
–Physical structure
–Body composition
–Organ function
•Sensory changes
–Vision
•Decreased vision (day and night)
•Hearing
–Inability to hear high frequency sounds
–Many require the use of hearing aids
•Other Changes
–Increased risk of infections
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Assessment and Care Implications
•Eye level
•Ensure good lighting
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EMS Operations
Phases of a Response
Preparation
Begins at the start of every tour with equipment check / restock
Medical equipment
Non-medical equipment
Compliance with Part 800 of NY State Public Health Law
Dispatch
Receive information including nature of call, location, number of patients,
special circumstances
En Route
Respond quickly and safely
Consider time of day, traffic patterns, etc
Arrival
Advise dispatch of arrival
Survey scene for potential hazards
Determine MOI / NOI
Request needed resources prior to initiating care
Operate in an organized / efficient manner
Post-Run Activities
Prepare for next run
Clean, restock and replace equipment
Complete all documentation thoroughly and honestly
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CFR Handout Manual – NYS DOH EMR Compliant – 2012- Revised May 2014
Air Medical Consideration
In the event that a helicopter is to be used for removal / transport of a
patient, identify a safe landing zone that is free and clear of overhead
wires, trees and debris.
Extrication
Extrication = removing a patient from that in which they are entrapped (the
vehicle, machinery, etc)
A patient should only be extricated from a vehicle prior to the arrival of EMS
if the patient’s condition warrants it (necessary care cannot be administered
unless the patient is moved) or if it is unsafe to leave the patient in the
vehicle.
Otherwise, if the scene is safe and the patient is stable, the patient should
be stabilized in the position found until EMS arrives and immobilizes the
patient.
Patient care precedes extrication unless delay would endanger the life of
the patient or rescuers.
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CFR Handout Manual – NYS DOH EMR Compliant – 2012- Revised May 2014
Hazardous Materials
SCENE SAFETY
Park and remain uphill, upwind and upstream at a safe distance from the
scene
DO NOT enter or approach the scene unless you are trained and equipped
to do so!
The first unit to arrive and recognize the existence of an MCI must
first advise the dispatcher and request additional resources prior to
initiating any care.
The most highly trained medical provider then assumes the role of Triage
Officer and initiates START.
The aim of triage = Do the greatest good for the greatest number
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CFR Handout Manual – NYS DOH EMR Compliant – 2012- Revised May 2014
START:
PROCEDURE:
Direct all walking wounded to a designated safe location and assign them
GREEN tags
Assess Respirations:
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CFR Handout Manual – NYS DOH EMR Compliant – 2012- Revised May 2014
Assess Circulation:
If radial pulse is absent, assign RED tag and continue to next victim
If radial pulse is present, continue assessment of this patient
BLACK = Non-viable
Life threats (blocked airways and arterial bleeding) are addressed during
triage. All other treatment is delayed until triage is complete and all
patients have been assigned a treatment priority.
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CFR Handout Manual – NYS DOH EMR Compliant – 2012- Revised May 2014
ABC-DIVERS
Primary
Assessment
• AIRWAY
• BREATHING
• CIRCULATION
• DECISION
Secondary
Assessment
• INTERVIEW
• VITAL SIGNS
• EXAM
• REASSESSMENT
• SUMMARY
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CFR Handout Manual – NYS DOH EMR Compliant – 2012- Revised May 2014
Patient Assessment Flow Sheet- CFR - Trauma
Primary Assessment:
Life Threats: Are there any immediate life threats to the patient?
Impression: appearance, position, level of consciousness
Stabilize: C-spine precaution as necessary
AVPU: assess patient’s mental status
History-Secondary Assessment:
Exam: Head to Toe:
Inspect and palpate for DOTS, manage secondary injuries
(scalp, ears, eyes, nose, mouth, trachea, JVD, L/S, genitalia,
PMS)
Log-roll patient (Inspect/palpate spine, buttocks)
Full set of vital signs: Blood pressure (systolic/diastolic)
Pulse & Respirations ( Rate, Rhythm and Quality)
Skin: Color, Temperature, and Condition
Sample History: Information pertaining to the patient
Reassessment: Repeat:
Primary Assessment
Secondary Assessment
2nd set of vital signs
Interventions
Every 5 minutes- critical patients
Every 15 minutes- stable patients
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CFR Handout Manual – NYS DOH EMR Compliant – 2012- Revised May 2014
Patient Assessment Flow Sheet- CFR - Medical (cardiac condition)
Primary Assessment:
Life Threats: Are there any immediate life threats to the patient?
Impression: appearance, position, level of consciousness
Stabilize: consider spinal stabilization
AVPU: assess patient’s mental status
Airway: Assess and maintain airway as needed (open, suction, OPA, NPA)
Breathing: Oxygen
Inspection (visual inspection checking for inadequate respirations)
Auscultate (Mid-Axillary at the nipple line)
History-Secondary Assessment:
Cardiac Patient-O,P,Q,R,S, T
(Onset, Provocation/Palliates, Quality, Radiation, Severity, Time
Sample History:
(S/S, Allergies, Medications, Past/pertinent history, Last oral intake,
events)
Reassessment:
Repeat: General impression
Primary assessment
Secondary assessment
Vital signs
Intervention (treatment)
Assess critical patients every 5 minutes
Assess stable patients every 15 minutes
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CFR Handout Manual – NYS DOH EMR Compliant – 2012- Revised May 2014
PATIENT ASSESSMENT FLOW SHEET-CFR - MEDICAL (RESP.)
Scene Size Up:
Is the scene safe?
Do I have enough BSI?
What’s the NOI (nature of illness)?
How many patients are there?
Do I need additional resources?
Primary Assessment:
Life Threats: Are there any immediate life threats to the patient?
Impression: Appearance, position, level of consciousness
Stabilize: Consider spinal stabilization
AVPU: Assess patient’s mental status
Airway: Assess and maintain airway as needed (open, suction, OPA, NPA, prn)
Breathing: Oxygen
Inspect (visual inspection checking for inadequate respirations
Auscultate (mid-axillary at the nipple line)
History-Secondary Assessment:
Sample History:
(S/S, Allergies, Medications, Past/pertinent history, Last oral intake, Events)
Reassessment:
Repeat Primary assessment
Secondary assessment
Vital signs
General impression
Interventions
Reassess: Every 5 minutes for critical patients
Every 15 minutes for stable patients
Scene Size-Up
BSI Gloves, goggles, mask, gown, prn
Scene safety Is the scene safe for you, your partner, & the patient?
MOI/NOI Determine mechanism of injury
Number of patients MCI ? Is one crew enough to handle the job?
Need for additional resources PD ? FD ? Additional BLS ? ALS ? Etc.
Primary Assessment:
Life threats/chief complaint: Correct any obvious life threats
Impression (general) Age, sex, position, apparent level of consciousness
Stabilize C-spine PRN
AVPU Assess mental status
Scene Size-Up
BSI Gloves, goggles, mask, gown, prn
Scene safety Is the scene safe for you, your partner, & the patient?
NOI/MOI Determine nature of illness or mechanism of injury
Number of patients MCI ? Is one crew enough to handle the job?
Need for additional resources PD ? FD ? Additional BLS ? ALS ? Etc.
Primary Assessment:
Life threats/chief complaint: Correct any obvious life threat. What is the patient’s most serious
complaint?
Impression (general) Age, sex, position, apparent level of consciousness
Stabilize Consider C-Spine precautions PRN
AVPU A Patient is oriented to person, place, time
V Patient response to verbal stimuli
P Patient response to painful/physical stimuli (gag reflex)
U Unresponsive
Airway: Open PRN Head-tilt/ chin-lift
Suction PRN any audible noises, FBAO maneuvers
OPA OPA/NPA PRN
Breathing: Oxygen: Adequate or inadequate respirations (NRB/BVM)
Inspect Chest wall visually –use discretion
Palpate Chest-PRN (use discretion)
Auscultate Mid-axillary for presence of lung sounds x2
Circulation: Bleeding Control obvious bleeding. Assess for internal bleeding
Carotid pulse If unresponsive
Radial pulse Compare peripheral with central pulses
Skin Color, temperature & Condition
Shock Maintain body temperature
Decision/dispatch: Identify priority patients, update EMS, obtains ETA
Secondary Assessment (History) - History of Present Illness Questions
O (Onset) “What were you doing when the symptoms began?”
P (Provokes/Palliates) “Is there anything that makes it feel better or worse?”
Q (Quality) “Can you describe the symptoms?”
R (Radiation) “Does the pain/symptoms travel anywhere? Do you feel it anywhere else?”
S (Severity) “On a scale of 0-10, 10 being the worse pain you’ve ever had, how bad is this?”
T (Time) “When did the symptoms begin? How long did they last?”
History: Sample history S- Signs and Symptoms Is there anything else bothering you?
A- Allergies Do you have any allergies?
M- Medications Prescription/over-the-counter
P- Past/pertinent history Do you have any medical problems?
L- Last oral intake When was the last time you ate/drank?
E- Events What happened prior to the problem?
Physical Exam: Vector physical exam to patient’s medical problem or condition
Cardiovascular
Central cyanosis, pursed lips
Pupillary reaction
Accessory muscle use/ retractions, lung sounds, equal chest expansion
Skin color, conjunctiva
JVD
Ascites, carpal/pedal edema
Vital signs: Blood pressure: Systolic/diastolic
Pulse: Rate & quality
Respirations: Rate & quality
Skin: Color, temperature and condition
Reassessment:
Repeat- General Impression
Primary assessment and Secondary Assessments
Vital signs
Intervention - Every 5 minutes for critical patients & Every 15 minutes for stable
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CFR Handout Manual – NYS DOH EMR Compliant – 2012- Revised May 2014
MEDICAL ASSESSMENT (CONSCIOUS) - RESPIRATORY
Scene Size-Up
BSI Gloves, goggles, mask, gown, prn
Scene safety Is the scene safe for you, your partner, & the patient?
NOI/MOI Determine nature of illness or mechanism of injury
Number of patients MCI ? Is one crew enough to handle the job?
Need for additional resources PD ? FD ? Additional BLS ? ALS ? Etc.
Primary Assessment:
Life threats/chief complaint: Correct any obvious life threat. What is the patient’s most serious
complaint?
Impression (general) Age, sex, position, apparent level of consciousness
Stabilize Consider C-Spine precautions PRN
AVPU A Patient is oriented to person, place, time
V Patient response to verbal stimuli
P Patient response to painful/physical stimuli (gag reflex)
U Unresponsive
Airway: Open PRN Head-tilt/ chin-lift
Suction PRN any audible noises, FBAO maneuvers
OPA OPA/NPA PRN
Breathing: Oxygen: Adequate or inadequate respirations (NRB/BVM)
Inspect Chest wall visually –use discretion
Palpate Chest-PRN (use discretion)
Auscultate Mid-axillary for presence of lung sounds x2
Circulation: Bleeding Control obvious bleeding. Assess for internal bleeding
Carotid pulse If unresponsive
Radial pulse Compare peripheral with central pulses
Skin Color, temperature & Condition
Shock Maintain body temperature
Decision/dispatch: Identify priority patients, update EMS, obtains ETA
Secondary Assessment (History) - History of Present Illness Questions
O (Onset) “What were you doing when the symptoms began?”
P (Provokes/Palliates) “Is there anything that makes it feel better or worse?”
Q (Quality) “Can you describe the symptoms?”
S (Severity) “On a scale of 0-10, 10 being the worse difficulty breathing you’ve ever had, how
bad is this?”
T (Time) “When did the symptoms begin? How long did they last?”
History: Sample history S- Signs and Symptoms Is there anything else bothering you?
A- Allergies Do you have any allergies?
M- Medications Prescription/over-the-counter
P- Past/pertinent history Do you have any medical problems?
L- Last oral intake When was the last time you ate/drank?
E- Events What happened prior to the problem?
Physical Exam: Vector physical exam to patient’s medical problem or condition
Respiratory
Central cyanosis, pursed lips
Pupillary reaction
Accessory muscle use/ retractions, lung sounds, equal chest expansion, shape of chest
Skin color,
Pedal edema,
Vital signs: Blood pressure: Systolic/diastolic
Pulse: Rate & quality
Respirations: Rate & quality
Skin: Color, temperature and condition
Reassessment:
Repeat- General Impression
Primary assessment
Secondary assessment
Vital signs
Intervention - Every 5 minutes for critical patients & Every 15 minutes for stable
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CFR Handout Manual – NYS DOH EMR Compliant – 2012- Revised May 2014
RAPID TRANSPORT
Actual or impending cardiorespiratory arrest
Cardiorespiratory instability, such as respiratory distress
Respiratory failure
2 or more long bone fractures
Severe upper respiratory difficulties
Trauma with associated burns
Rising intracranial pressure
Amputation proximal to wrist & ankle
Decompensated shock (hypoperfusion)
Chest pain with B/P < 100/Palp
Severe pain
Poor general impression
Unresponsive patients
Patient responsive but unable to follow commands
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CFR Handout Manual – NYS DOH EMR Compliant – 2012- Revised May 2014
HISTORY OF THE PRESENT ILLNESS (HPI) QUESTIONS
RESPIRATORY OR CARDIAC
Onset “What were you doing when the symptoms began?”
Provokes (or Palliates) “Is there anything that makes it feel better or worse?”
Quality “Can you describe the symptoms?”
Radiates (or Refers) “Does the pain travel anywhere? Do you feel it anywhere?
Severity “On a scale of 1-10, 10 being the worst, how bad is it?”
Time “When did the symptoms begin? How long did they last?”
Interventions “Have you done anything to try to correct the problem?”
AMS
Description of the episode “What happened?”
Onset “What was the patient doing when the symptoms began?”
Duration “How long did it last?” or “How long has it being going on?”
Associated symptoms “Is there anything else bothering the patient?”
Evidence of trauma “Did you injured yourself?” or verbalize looking for injuries
Interventions “Have you done anything to try to correct the problem?”
Seizures “Did you have a seizure?” “Did the patient have a seizure?”
Fever “Do you have a fever?” “Does the patient have a fever?”
ALLERGIC REACTION
History of allergies “Do you have allergies?”
What were you exposed to? “What were you exposed to?”
How were you exposed? “How were you exposed? (ingestion, infection, inhalation)”
Effects “What are your symptoms?”
Progression “How fast did the symptoms come on?”
Interventions “Have you done anything to try to correct the problem?”
POISONING/OVERDOSE
Substance “What did you take?”
When did you ingest/become exposed? “When did you ingest/become exposed?”
How much did you ingest? “How much did you ingest?”
Over what time period? “Did you take it/were you exposed all at once?”
Interventions “Have you done anything to try to correct this?”
ENVIRONMENTAL EMERGENCY
Source Identify the source of the patient’s exposure
Environment Verbalize identification of the type of exposure
Duration “How long were you exposed?”
Loss of consciousness “Did you lose consciousness”
Effects of general or local Verbalize identification of local injury or systemic problem
OBSTETRICS
Are you pregnant? “Are you pregnant?”
How long have you being pregnant? “How long have you being pregnant?”
Pain or contractions “Are you having pain or contractions?”
Bleeding or discharge “Is there any bleeding or discharge?”
Has water broken? “Has your water broke?”
Do you feel the need to push? “Do you feel the need to push/move your bowels?”
Last menstrual period “When did your last menstrual period began??
BEHAVIORAL
How do you feel? “How do you feel?”
Determine suicidal tendencies “Have you ever tried to hurt yourself?”
Is the patient a threat to self or others? “Do you feel the desire to hurt yourself or anyone else now?”
Is there a medical problem? Verbalize eliminating the possibility of medical problem
Interventions Have you done anything to try to correct the problem
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CFR Handout Manual – NYS DOH EMR Compliant – 2012- Revised May 2014
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